August 22, 2009

Earlier this year (2009) the Commonwelth Fund Commission issued multiple reports asserting a goverment-run health care plan could cut insurance premiums approximatly 20%. It asserts that private insurance spends 40% of claims costs on administrative expenses. The Sherlock Company was commissioned to do a study of private insurance costs in 2009 (the study most frequently quoted in the debate today dates from 1988).

I. Executive SummaryHealth plan administrative expenses often are cited as consuming a significant share of health insurance premiums. Proponents of a public health insurance plan often state that Medicare is more efficient than private insurance companies. However, these statements are based on outdated data and misconceptions about private administrative expenses, especially in the small group and individual markets.

Recent reports claim that health plan administrative expenses in the individual and small employer markets can exceed 30%. However, these estimates are based on data from Hay-Huggins that is more than 20 years old (1988) — a time when most claims were paper-based and many electronic processes were in their infancy — and based on estimated, rather than actual, administrative costs for companies that no longer provide health insurance.An independent analysis by Sherlock Company of health plan administrative costs finds that prior estimates do not reflect the actual administrative costs for Blue Cross and Blue Shield Plans and other major health plans. Based on our review of actual health plan administrative expenses, we find that:

• Private health plan administrative expenses are grossly overstated in previous reports.Based on combined data from 36 health plans participating in our performance benchmarking studies in 2008 (2007 data) and other data, administrative expenses for all commercial products represented 9.18% of premiums. Administrative costs are 11.12% of premiums for the small group market and 16.35% of the individual market, amounts that are nearly one-half and in some cases nearly one-third of other estimates.

• Traditional Medicare performs only a fraction of the administrative functions of private health plans because it retains its original fee-for-service design and is, therefore, not comparable.Private plans use their administrative costs to promote care coordination and wellness, reduce unnecessary utilization and aggressively combat fraud and abuse. No precise, generally accepted measure of Medicare administrative expenses exists that is comparable to private plans. Moreover, Medicare does not need to market its coverage, develop provider networks, negotiate provider rates or maintain capital. If the government were to create a public health option to compete with private plans in a health insurance exchange, it would have to take on many additional functions that are not part of Medicare’s administrative costs today, resulting in increased administrative costs.

• Private plans perform those administrative functions that Medicare performs at lower costs.In comparing only those administrative functions that Medicare performs, private administrative costs are actually lower — $12.51 per member per month, compared to a $13.19 per member per month in traditional Medicare. Many of Medicare’s administrative functions are, in fact, performed by private administrative contractors.

• Comparing administrative expenses between Medicare beneficiaries and people under age 65 should consider the unique healthcare needs of seniors.Medicare beneficiaries have higher costs per claim compared to private plan enrollees. This means that the service requirements are less per dollar of health benefit, and administrative expenses are less for Medicare simply by virtue of the higher cost per claim.

• Comparing administrative costs as a percentage of claims overstates the differencebetween plans for small groups or individuals and large groups.Instead of calculating administrative expenses as a percentage of premiums, which is the most conventional metric used for comparing administrative costs, Hay-Huggins and subsequent reports have expressed the values as a percentage of claims, which is very misleading. Because health insurance premiums pay for both health claim costs and administrative expenses, the Hay-Huggins approach, repeated by Lewin, of dividing administrative expenses by claims costs unrealistically magnifies the differences between administrative expense ratios.